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<title>AHA/ACSM Health/Fitness Facility Pre Participation Screening Questionnaire</title>
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    <h3>Health / Fitness Pre-Participation Questionnaire:</h3>
			<p style="color:gray; font-size: 12px;">AHA/ACSM Health/Fitness Facility Pre Participation Screening Questionnaire</p><br/>
			<ul id="yes-no">
				<li>
                    <span style="margin-left: 14px; margin-left: -6px;">I have had:</span><br/>					
					<span style="color:gray; font-size: 12px;">If you marked any of the statements in this section, consult your physician or other appropriate healthcare provider before engaging in exercise. You may need to use a facility with a medically qualified staff.</span><br/>
					<span style="font-weight: bold; margin-left: -6px;">History:</span><br />
                    <asp:CheckBoxList ID="chkBxHistory" runat="server" CssClass="chkBxList">
                        <asp:ListItem Value="A heart attack">A heart attack</asp:ListItem>
                        <asp:ListItem Value="Heart surgery">Heart surgery</asp:ListItem>
                        <asp:ListItem Value="Cardiac catheterization">Cardiac catheterization</asp:ListItem>
                        <asp:ListItem Value="Coronary angioplasty (PTCA)">Coronary angioplasty (PTCA)</asp:ListItem>
                        <asp:ListItem Value="Pacemaker/implantable cardiac defibrillator/rhythm disturbance">Pacemaker/implantable cardiac defibrillator/rhythm disturbance</asp:ListItem>
                        <asp:ListItem Value="Heart valve disease">Heart valve disease</asp:ListItem>
                        <asp:ListItem Value="Heart failure">Heart failure</asp:ListItem>
                        <asp:ListItem Value="Heart transplantation">Heart transplantation</asp:ListItem>
                        <asp:ListItem Value="Congenital heart disease">Congenital heart disease</asp:ListItem>                       
                    </asp:CheckBoxList>
                </li>
				<li>
					<span style="font-weight: bold; margin-left: -6px;">Symptoms:</span><br />
					<asp:CheckBoxList ID="chkBxSymptoms" runat="server" CssClass="chkBxList">
                        <asp:ListItem Value="A heart attackYou experience chest discomfort with exertion.">I experience chest discomfort with exertion.</asp:ListItem>
                        <asp:ListItem Value="I experience unreasonable breathlessness.">I experience unreasonable breathlessness.</asp:ListItem>
                        <asp:ListItem Value="I experience dizziness, fainting, blackouts.">I experience dizziness, fainting, blackouts.</asp:ListItem>
                        <asp:ListItem Value="I take heart medications.">I take heart medications.</asp:ListItem>
                    </asp:CheckBoxList>
				</li>
				<li>
					<span style="font-weight: bold; margin-left: -6px;">Other health issues:</span><br />
					<asp:CheckBoxList ID="chkBxOther" runat="server" CssClass="chkBxList">
                        <asp:ListItem Value="I have diabetes.">I have diabetes.</asp:ListItem>
                        <asp:ListItem Value="I have or asthma other lung disease.">I have or asthma other lung disease.</asp:ListItem>
                        <asp:ListItem Value="I have burning or cramping in my lower legs when walking short distances.">I have burning or cramping in my lower legs when walking short distances.</asp:ListItem>
                        <asp:ListItem Value="I have musculoskeletal problems that limit my physical activity.">I have musculoskeletal problems that limit my physical activity.</asp:ListItem>
                        <asp:ListItem Value="I have concerns about the safety of exercise.">I have concerns about the safety of exercise.</asp:ListItem>
                        <asp:ListItem Value="I take prescription medication(s).">I take prescription medication(s).</asp:ListItem>
                        <asp:ListItem Value="I am pregnant.">I am pregnant.</asp:ListItem>
                    </asp:CheckBoxList>

                    <div class="rule"></div>
				</li>				
				<li>
				<span style="color:gray; font-size: 12px;">If you marked two or more of the statements in this section, you should consult your physician or other appropriate healthcare provider before engaging in exercise. You might benefit by using a facility with a professionally qualified exercise staff to guide your exercise program.</span><br/>
					<span style="font-weight: bold; margin-left: -6px;">Cardiovascular risk factors:</span><br />
					<asp:CheckBoxList ID="chkBxCardiovascular" runat="server" CssClass="chkBxList">
                        <asp:ListItem Value="I am a man older than 45 years.">I am a man older than 45 years.</asp:ListItem>
                        <asp:ListItem Value="I am a woman older than 55 years, I have had a hysterctomy, or I am postmenopausal.">I am a woman older than 55 years, I have had a hysterctomy, or I am postmenopausal.</asp:ListItem>
                        <asp:ListItem Value="I smoke, or quit within the previous 5 month.">I smoke, or quite within the previous 5 month.</asp:ListItem>
                        <asp:ListItem Value="My BP is greater than 140/90.">My BP is greater than 140/90.</asp:ListItem>
                        <asp:ListItem Value="I don't know my BP.">I don't know my BP.</asp:ListItem>
                        <asp:ListItem Value="My blood cholesterol level is >200 mg/dl.">My blood cholesterol level is &rsaquo;200 mg/dl.</asp:ListItem>
                        <asp:ListItem Value="I don't know my cholesterol level.">I don't know my cholesterol level.</asp:ListItem>
                        <asp:ListItem Value="I have a close blood relative who had a heart attack before age 55(father or brother) or age 65 (mother or sister)">I have a close blood relative who had a heart attack before age 55(father or brother)<br/><span style="padding-left: 48px;">or age 65 (mother or sister).</span> </asp:ListItem>
                        <asp:ListItem Value="I am physically inactive (i.e. I get less than 30 min. of physical activity on at least 3 days per week).">I am physically inactive (i.e. I get less than 30 min. of physical activity on at least 3 days per week).</asp:ListItem>
                        <asp:ListItem Value="I am more than 20 pounds overweight.">I am more than 20 pounds overweight.</asp:ListItem>
                    </asp:CheckBoxList>
                    <div class="rule"></div>
					<asp:CheckBox runat="server" ID="chkBxNone" value="none"/>None of the above is true.<br/>										
					<span style="color:gray; font-size: 12px;">You should be able to exercise safely without consulting your physician or other healthcare provider in a selfguided program or almost any facility that meets your exercise program needs</span>
				</li>
			</ul><br/>
			<p style="font-size: 11px; color: gray;">				
				Balady et al. (1998). AHA/ACSM Joint Statement: Recommendations for Cardiovascular Screening, Staffing, and Emergency Policies at Health/Fitness 
				Facilities. Medicine <br/> &amp; Science in Sports &amp; Exercise, 30(6).  (Also in: ACSM’s Guidelines for Exercise Testing and Prescription, 7
				th Edition, 2005. Lippincott Williams and Wilkins <a href="http://www.lww.com" target="_blank">http://www.lww.com</a>)<br/>				
				<a href="www.acsm-msse.org/pt/pt-core/template-journal/msse/media/0698c.htm" target="_blank">www.acsm-msse.org/pt/pt-core/template-journal/msse/media/0698c.htm</a>
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